For organ or tissue pledging (To be filled by individual of age 18 year or above) [See rule 5(4)(a)]

ORGAN(S) AND TISSUE(S) DONOR FORM (To be filled in triplicate) Registration Number (To be allotted by Organ Donor Registry)........................... I ...........................................................................S/o,D/o,W/o...............................................................aged....................................and date of birth ........................................................................ resident of....................................................................................in the presence of persons mentioned below hereby unequivocally authorise the removal of following organ(s) and/or tissue(s), from my body after being declared brain stem dead by the board of medical experts and consent to donate the same for therapeutic purposes. Please tick as applicable (Following tissues can also be donated after brain stem death as well as cardiac death) Heart ☐ Corneas/Eye Balls ☐ Lungs ☐ Skin ☐ Kidneys ☐ Bones ☐ Liver ☐ Heart Valves ☐ Pancreas ☐ Blood Vessels ☐ Any Other Organ (Pl. specify) All Organs ☐ Any other Tissue (Pl. specify) All Tissues ☐ My blood group is (if known)...................................................... Signature of Pledger...................................... Address for correspondence...................... Telephone No........................................ Email : .......................................... Dated: (Note: In case of online registration of pledge, one copy of the pledge will be retained by pledger, one by the institution where pledge is made and a hard copy signed by pledger and two witnesses shall be sent to the nodal networking organisation.) (Signature of Witness 1) 1. Shri/Smt./Km....................................................................S/o,D/o,W/o................................................................................ aged......................... resident of.............................................................................Telephone No..................................................Email:........................................................ (Signature of Witness 2) 2. Shri/Smt./Km....................................................................S/o,D/o,W/o................................................................................ aged......................... resident of......................................... Telephone No........................................ Email:................................ is a near relative to the donor as..................................... Dated.............................. Place ............................... Note: (i) Organ donation is a family decision. Therefore, it is important that you discuss your decision with family members and loved ones so that it will be easier for them to follow through with your wishes. (ii) One copy of the pledge form/pledge card to be with respective networking organisation, one copy to be retained by institution where the pledge is made and one copy to be handed over to the pledger. (iii) The person making the pledge has the option to withdraw the pledge.